advancing medical homes: the role of pathology

Advancing Medical Homes:The Role of PathologyJames M. Crawford, M.D., Ph.D.

Department of Pathology and Laboratory MedicineNorth Shore-Long Island Jewish Health System

Hofstra University School of Medicine

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1800’s: “Pathology” = morbid anatomy of the autopsy, laboratory research

1890’s – 1920’s: Introduction of “frozen section”; growth of Surgical Pathology

1850 – 1900: Birth of Bacteriology; analysis of body fluids f1850 – 1900: Birth of Bacteriology; analysis of body fluids

1900 – 1920’s: Expansion of laboratory diagnostics

1926: ACOS requirement: all specimens to Pathology

1926: Medical Testing Act: Lab testing = “Practice of Medicine”

1946: AMA recognizes Pathology = “Practice of Medicine”

United States of America

Pathology at the dawn of Population Health

The lambast against American Medicine*

• “America is the only country that spends its money first on specialty care, and then we work our way down until the money runs out.”

• “In the USA, there is $700B of wasted medical care per year.”• “Healthcare is the only industry where, at the point of purchase, we

don’t know how much it is going to cost, and who is going to pay for it.”

• With regards to delivery of healthcare: “We can’t tell what already has been done, and what doesn’t need to be done.”

*Tom Daeschle, 11/9/09

Patient

Payer HealthcareProvider

Step

1: I

nsur

ance

cove

rage

Step 2: Delivery of Healthcare

Step 3: Reconcile payment

Limited knowledge of

prior medical care

Our “toxic” environment

“Why is it that IBM pays twice as much for health care in theUnited States, and gets only half the value (as Europe)?”Paul Grundy, Chief Medical Officer, IBM (2005)

“Never has so much bought so little, for so few”American Association of Family Physicians (2006)

The two catch-phrases

“Bend the Curve” runaway healthcare costs as % of GDP

“Invert the Pyramid” primary care versus specialty/acute care

BUT:

“Our nation’s medical schools are toxic to Primary Care.”American Association of Family Physicians (2009)

Personal Epiphany

It is our “watch”.

The forces in motion now will determine the trajectory of our specialty for the generation of Pathologists that follows us.

More specifically…

How does Pathology turn the corneron “Primary Care”, “Access” and “Population Health”?

Personalized Medicine

Patient Centered Medical Home

Population-based Healthcare Outcomes

ACCE

SS

MEDICAL SCIENCE

HIT

American Recovery and Reinvestment Act 2009

Page 354:

(C) NON-APPLICATION TO HOSPITAL-BASED ELIGIBLE PROFESSIONALS.—(i) IN GENERAL.—No incentive payment may be made under this paragraph in the case of a hospital-

based eligible professional.(ii) HOSPITAL-BASED ELIGIBLE PROFESSIONAL.—For purposes of clause (i), the term ‘hospital-

based eligible professional’ means, with respect to covered professional services furnished by an eligible professional during the EHR reporting period for a payment year, an eligible professional, such as a pathologist, anesthesiologist, or emergency physician, who furnishes substantially all of such services in a hospital setting (whether inpatient or outpatient) and through the use of the facilities and equipment, including qualified electronic health records, of the hospital. The determination of whether an eligible professional is a hospital-based eligible professional shall be made on the basis of the site of service (as defined by the Secretary) and without regard to any employment or billing arrangement between the eligible professional and any other provider.

Healthcare Reform Act2010

-32 million additional insured Americans; 16 million through Medicaid-Improvements to Medicare Prescription Drug Program-Ban on future Physician-owned Hospitals-Increased Payments for Primary Care, “Teaching Health Centers*-Funding of pilots for Patient Centered Medical Home*-Funding of pilots of “Health Innovation Zones”*-Preservation of Indirect Medical Education (IME) payment to hospitals-Redistribution of unused Graduate Medical Education (GME) slots-Reduction in disproportionate share funding of Safety Net Hospitals-Scheduled Medicare cuts to Hospitals that don’t meet quality metrics*-2013: Begin Pilot on Medicare “Bundled Payments”, expand in 2015*-Supports formation of Accountable Care Organizations*-Establishes CMS Center for Medicaid and Medicare Innovation (CMI)-Establishes Congressional Independent Payment Advisory Board-Silent on correction of Medicare “Sustained Growth Rate” (SGR)

Enter the concept of:“Patient Centered Medical Home”

“Patient Centered Medical Neighborhood”

PCMH: DefinitionAn approach to providing comprehensive primary care through a healthcare setting thatfacilitates partnerships between individual patients, their personal physicians, and, when appropriate, the patient’s family.

• Each patient has a personal physician• This personal physician directs the primary medical care received by the patient• The personal physician takes responsibility for arranging care for all of the patient’s

health needs• The personal physician coordinates the patient’s care across all elements of the

complex health system

Patient Centered Medical HomeOPERATIONAL PRINCIPLES• Healthcare quality and safety are integral objectives of a PCMH• Patients should have enhanced access to healthcare through the PCMH• Payment for healthcare services should recognize the added value

provided to patients who have a patient-centered medical home

EXPECTATIONS• Excessive utilization of healthcare services will be reduced• The “patient experience” will improve• Primary Care Providers will have more time to spend with their patients• The healthcare outcomes of the population will improve

PCMH: Brief History1967 American Academy of Pediatrics (AAP): concept of a chronic care “home”2001 Institute of Medicine (IOM) report: Crossing the Quality Chasm: A New Health

System for the 21st Century2005 Institute of Medicine (IOM) report: Building a Better Delivery System: A New

Engineering/Health Care Partnership2004 American Academy of Family Physicians (AAFP): endorses PCMH2006 American College of Physicians (ACP): endorses PCMH

American Osteopathic Association (AOA): endorses PCMH

2006 Patient Centered Primary Care Collaborative (PCPCC) established2007 Joint Principles for PCMH articulated by AAP, AAFP, ACP, AOA

National Committee for Quality Assurance (NCQA; founded 1990) incorporatesJoint Principles into their “Physician Practice Connections” (PPC) guidelines

2008 NCQA begins deeming physician practices for meeting PPC-PCMH standardsSelected NCQA-deemed physician practices identified as “demonstration programs”

2009 American Recovery and Reinvestment Act (ARRA): $30B of adoption incentives for“meaningful use” of certified Electronic Health Records (EHR) : Medicare

New York, Ohio, Pennsylvania, Oklahoma….: PCMH incentives for Medicaid

Patient Centered Primary Care Collaborative

2005 IBM (Paul Grundy): In the U.S., it costs IBM twice as much to get ½ thevalue of employee healthcare outcomes, vs. other industrialized countries

Primary Care is the only entity charged with the longitudinal care of thewhole patient, and it is this longitudinal care which has the most profoundeffect on healthcare outcomes.

www.pcpcc.net

What is the role of Pathology in the “Patient Centered” Healthcare?

Sinard & Morrow, Human Pathol 2001; 32: 143-148

Patient

Specialists

Rehabilitation Acute Care

Home Care

Imaging

Labs

Insurance

Employer

Community

Patient Centered Health Care

ca. 2010

The position of the Office of the National Coordinator*

• It is the local multistakeholder alliances that will effect change.• Information is the lifeblood of medicine.• ‘Meaningful use’ is the key to unlocking the potential of Health IT

for Primary Care, Specialty Care, and Hospitals, because it focuses not on the technology but on its use.

• Five domains of focus:- Quality, Safety, Efficacy, Access- Public and Population Health- Engagement of Patients and Families- Coordination of Care- Privacy and Security

• These domains accord perfectly with the PCMH.*David Blumenthal, 3/30/2010

PCMH and Pathologya personal journey

2007-2008 University of Florida Pathology/Lab Med: Diabetes Wellness Program (Disney)Premise: Laboratory Medicine is the underpinning for disease management

2008 Idea of PCMH introduced to:CAP Council of Government and Professional Affairs (Jan 2008)APC Council (Jul 2008)

September: CAP and APC endorse concept, join the PCPCCDecember: Crawford appointed Co-Chair of the PCPCC CeHIA

2009 April: PCPCC CeHIA releases “Meaningful Connections”Report on use of HIT in support of the PCMH

May: Chair of “CeHIA HIT Resource Center Task Group”June-Aug: PCPCC in contact with ONC, AHRQ about federal HIT efforts

Drafting of PCPCC White Paper for ONC: PCPCC support of HITEC-informing ONC on “patient-centered healthcare”-serving as convener of stakeholders, disseminating information

2010 Current assignment: work with AHRQ on “HIT Resource Center”, includingparticipation in AHRQ design of web presence

PCMH and Pathology

2009 April: CAP CGPA creates “Pathologyand PCMH” as a top priority for advocacy

2010 ASCP examining PCMH as a priority

Information Management Requirements†

Patient Access and Communication appointment schedulingclinical information/PHR*education informationself-management support

Patient Tracking and Registry organizing clinical data*managing disease conditions*

Care Management guidelines, Decision Support*electronic prescribingtest tracking*tracking referralstracking Continuum-of-Care*

†National Committee for Quality Assurance 2008


*Pathology: primary dataor potential coordinator

Performance Reporting and Improvement

Measures of physician and practice performance*Measures of healthcare outcomes

Safety and Quality of healthcare*Specific disease management outcomes*

Patient experience and satisfaction

Ed note: These tools help the physician practice achieve improved outcomes;they are not construed as a “policing” function

National Committee for Quality Assurance 2008



Patient Management

Previsit planning (Laboratory testing*, Radiology testing, Dietary restriction)Patients needing clinical review or action*Monitoring patients on specific medicationsPatients needing reminders for preventive care, specific tests, follow-up*Patients who might benefit from care management support*



Population Management

Integrated clinical data from all care sites*Integrated ancillary data (e.g., all laboratory tests, all referrals)*Healthcare Resource utilization

Physician office visits, use of ancillaries, need for acute care*Real-time tracking of Claims data*

to include use of Pharmaceuticals*Real-time tracking of Safety and Quality Outcomes*Real-time tracking of the Patient Experience*Disease Management Outcomes*Biometrics (e.g., weight, body-mass index, blood pressure)*Laboratory values as proxy (e.g., HbA1c, lipids)*Data on Lifestyle management (e.g., activities, dietary education)*



Clinical Endpoints

Resolution of medical condition(s)*

Addition of co-morbid or new conditions*

Escalation of care environment*

Acute-care intervention (e.g., hospitalization, surgery)*

Death*



Outcomes Assessment

Physician Practice outcomes*Testing of Evidence-Based Medicine within your healthcare organization*Testing and validation of Safety and Quality initiatives*Identification of Adverse Events*Patient Compliance*Efficacy of Lifestyle, Wellness, and Disease Management programs*Access to Preventive Screening programs*Delivery of healthcare at lowest cost service location*Return-on-investment of HIT solutions and the PCMH*Biometrics (e.g., weight, body-mass index, blood pressure)*Laboratory values as proxy and as primary data (e.g., HbA1c, lipids)*Data on Lifestyle management (e.g., activities, dietary education)*



There is no current payment model for these “pathology” activities- ? Consultation for appropriate test utilization ?*- ? Access to “pathology-specific” demonstration projects ?*

We are excluded by federal law from receiving “practice” payments

When (not “if”) ‘Bundled Payments’ arrive, the allocation of funding will be a local event. Where will Pathologists be if not already recog-nized locally for their professional role in patient management?

Payment issues

*College of American Pathologists: current advocacy

What-if

Master Patient Registry

Laboratory Information System

In-Patient EHR Ambulatory EHR

Registration and Billing

RHIOPatient Experience

Patient Outcomes

PremisePathologists are physician leaders first, and can utilize their extraordinary professional skills to promote improved healthcare outcomes across the populations they serve.

Corollary:Pathologists have to step forward as leaders within theirregional health systems.

With regards to Health Information Technology

• Pathologists need to get out of the LIS space and into the EHR space (and potentially the PHR space)

• Pathologists have a central role to play in the Patient CenteredMedical Home and other healthcare models that focus on patient-centric care

ConclusionsPathology/Laboratory Medicine is central to patient management.The “Medical Neighborhood” spans out-patient and in-patient encounters.Pathology/Laboratory Medicine supports the “Medical Neighborhood”, and is **not**

just a “hospital-based practice”.Pathology/Laboratory Medicine provides the primary data for much of healthcare

outcomes assessment; if not, it is a superb proxy for patient encounters,compliance, and quality of outcomes.

The Patient Centered Medical Home is likely to be a centerpiece of healthcarereform, and is the entry point to the Medical Neighborhood.

Pathology/Laboratory Medicine is partner, and potential leader, in promotingimproved healthcare outcomes in the national Healthcare Reform effort.

Failure to play an active role risks relegating our activities to being a commodity only.

advancing medical homes: the role of pathology

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